Viewpoint: A long-term plan for the NHS: now we need a vision for health, care and wellbeing – Part 2

Christine Heron has been examining the implications of the NHS Long Term Plan (LTP). In this second blog she looks at health, wellbeing and prevention.

Since transferring to local government in 2013, public health has made great progress, with well-performing public health teams having the following characteristics, and many others:

A health in all policies (HIAP) approach – for example, councils are working to curb clustering of fast food outlets, gambling, and alcohol licenses in areas where this has a negative impact on health. Public health is automatically involved in advising on major planning developments.

Public health services like stop smoking, and drugs and alcohol have been recommissioned to make sure they are cost-effective, outcome-based, provide accessible services in community settings or online, and tackle health inequalities.

Health and wellbeing services are well advertised so local people know where to go for help. Some are integrated, so if someone receives a service to lose weight but has financial problems, they will be referred to debt advice.

Public health data analysis and intelligence is helping to shape integrated health and social care and prevention, including population health management.

Local partners are responding to a wide range of priorities to tackle the social determinants of health – mental health in rural areas, domestic violence, employment, and many others.

This excellent work is more remarkable in the context of a reduction to public health grant funding of over £700m in real terms between 2015/16 and 2019/20. This includes continuing with cuts in 2019/20 at a time when the NHS will receive additional funding of £20.5bn over five years, and prevention is high on the national agenda.

Locally, progress happens when councils, the NHS and other partners collaborate to improve health and wellbeing together. Nationally, the LTP sets out several ways in which the NHS will increase its contribution to prevention and tackling health inequalities.

CCG funding allocations will more accurately reflect health inequalities, with all areas required to set measurable goals for reducing health inequalities.

Up to £30m additional funding for the health needs of rough sleepers and homeless people.

By 2023/24 smokers admitted to hospital to be offered support to quit, there will be a new smoke free pregnancy pathway, and a new universal offer in specialist mental health services.

A doubling of the diabetes prevention programme over the next five years.

An expansion of NHS specialist clinics for people with serious gambling problems.

A focus on the best start for children.

In light of the above, it is very disappointing that in the LTP NHS England also said that the government and the NHS will “consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors and school nurses, and what best future commissioning arrangements might therefore be”.

Sources indicate that this came as a shock to those who had been involved in the prevention work-strand of the LTP. Also, NHS England had originally wanted to specify a much larger range of public health functions (Health Service Journal 18th January). We can speculate that these would have included the other services named in this section of the LTP – smoking cessation and drug and alcohol services.

If it is the case that NHS England believes the NHS would do a better job commissioning and providing public health services, this flies in the face of evidence. In the past six years, 80 per cent of the 112 indicators in the public health outcomes framework have been level or improving (LGA analysis). There are numerous examples of how public health in local government has established innovative, cost-effective services based on outcomes co-production with stakeholders:

integrated support for children 0-19 and families imaginatively joined up with schools, children’s centres, early years services and child and adolescent mental health services (CAMHS)

online sexual health support resulting in higher levels of diagnosis and treatment

drug and alcohol services that include social and economic wellbeing as part of recovery.

The list of good practice carried out in many council areas is extensive.

PHE Chief Executive Duncan Selbie has said the LTP was referring to a joint review between local government and the NHS to achieve better joined-up working but “the rationale for local government to lead on public health remains unchanged”.

All has gone quiet on the Green Paper on prevention signalled by the DHSC’s November report “Prevention is better than cure” but possibly the two may be connected.

The Association of Directors of Public Health (ADPH), the Kings Fund, the LGA and others have all rightly pointed out that the suggestion in the LTP is an unhelpful distraction. What is needed is proper funding of public health, not tinkering with structures and responsibilities. We need to take our lead from the best local health and care partnerships and work together!